Provider Demographics
NPI:1649273111
Name:BOONE, SUSAN LOUELLA (RN,CNM,MS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LOUELLA
Last Name:BOONE
Suffix:
Gender:F
Credentials:RN,CNM,MS
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4422 S MCCOLL RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-9608
Mailing Address - Country:US
Mailing Address - Phone:956-423-4030
Mailing Address - Fax:956-423-9188
Practice Address - Street 1:1717 N ED CAREY DR
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8203
Practice Address - Country:US
Practice Address - Phone:956-423-4030
Practice Address - Fax:956-423-9188
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX603637367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1732604-01Medicaid
TX8D5711Medicare PIN
TXQ05880Medicare UPIN